Reducing percutaneous cholecystostomy for acute calculous cholecystitis: A multisite quality improvement initiative

Abstract

Background: Laparoscopic cholecystectomy is the gold standard for treating acute calculous cholecystitis, whereas percutaneous cholecystostomy is typically reserved for patients at prohibitive surgical risk, given its greater complication rates. This multisite quality improvement initiative aimed to reduce the use of percutaneous cholecystostomy in patients at acceptable risk for surgery.

Methods: In October 2023, a multidisciplinary team implemented an acute calculous cholecystitis care pathway across 8 teaching hospitals. Prohibitive surgical risk was defined as predicted mortality exceeding 10% by the American College of Surgeons National Surgical Quality Improvement Program Calculator, Child-Pugh Class C cirrhosis, or American Society of Anesthesiologists class IV. Adult patients with acute calculous cholecystitis were identified using International Classification of Diseases, Tenth Revision, codes 1 year before and after implementation.

Results: Among 2,948 patients (1,438 pre- and 1,510 postimplementation), use of percutaneous cholecystostomy decreased from 9.7% to 7.2% (P = .01), reaching a nadir of 4.4%. More recipients of percutaneous cholecystostomy met prohibitive-risk criteria postintervention (51.4% vs 67.3%; P = .02). Risk-adjusted analysis showed reduced odds of percutaneous cholecystostomy (odds ratio, 0.71; 95% confidence interval, 0.62-0.80) and 30-day mortality (odds ratio, 0.60; 95% confidence interval, 0.51-0.70) after implementation. LC rates increased (94.5-96.3%, P = .047), whereas open surgery declined. Minor bile duct leaks increased from 0.9% to 2.1% (P = .031), largely among patients with gangrenous disease or subtotal cholecystectomy. No major duct injuries occurred. Reoperation, cost, readmission, and length of stay were unchanged.

Conclusion: Implementation of a structured acute calculous cholecystitis pathway was associated with lower percutaneous cholecystostomy use and improved mortality, with a modest increase in minor bile leaks likely reflecting greater surgical complexity. Broader applicability warrants further evaluation.